Central Health Embrace Choice Plan (HMO C-SNP) - H5649-026-004

Doctor Office Visit:
Copayment for Primary Care Office Visit $0

Doctor Specialty Visit:
Coinsurance for Physician Specialist Office Visit 0% to 30%
Prior Authorization Required for Doctor Specialty Visit

Referral Required for Doctor Specialty Visit

Minimum coinsurance applies to endocrinologists. Maximum coinsurance applies to all other specialists.

Acute Hospital Services:

$1,676 deductible

• $0 copay per day for days 1-60

• $419 copay per day for days 61-90

• $838 copay per day for each lifetime reserve day

These are 2025 cost-sharing amounts and may change for 2026. We will provide updated rates at www.centralhealthplan.com as soon as they are released. 

Prior Authorization Required for Acute Hospital Services
Referral Required for Acute Hospital Services

Urgent Care:
Copayment for Urgent Care $0

Worldwide Coverage:
Copayment for Worldwide Urgent Coverage $110
Maximum Plan Benefit of $50,000

Emergency Care:
Copayment for Emergency Care $115
Copayment for Medicare Covered Emergency Care waived if you are admitted to the hospital with in 3 days.

Worldwide Coverage:
Copayment for Worldwide Emergency Coverage $110
Copayment for Worldwide Emergency Transportation $110
Maximum Plan Benefit of $50,000

Ground Ambulance:
Coinsurance for Ground Ambulance Services 20%

Prior authorization required for non-emergent ambulance only. 

Air Ambulance:
Coinsurance for Air Ambulance Services 20%
Prior Authorization Required for Air Ambulance

Chiropractic Services:
Copayment for Medicare-covered Chiropractic Services $0
Copayment for Routine Care $0

• Maximum 30 Routine Care every year combined with Routine Acupuncture services.

Prior Authorization Required for Chiropractic Services
Referral Required for Chiropractic Services

Diabetic Supplies and Services:
Copayment for Medicare-covered Diabetic Supplies $0
Copayment for Medicare-covered Diabetic Therapeutic Shoes or Inserts $0

Prior authorization may be required.

Prior authorization is not required for preferred manufacturer.

Durable Medical Equipment:
Coinsurance for Medicare-covered Durable Medical Equipment 20%
Prior Authorization Required for Durable Medical Equipment

Outpatient Diag Procs/Tests/Lab Services:

Coinsurance for Medicare-covered Diagnostic Procedures/Tests 0% to 20%
Copayment for Medicare-covered Lab Services $0
Prior Authorization Required for Outpatient Diag Procs/Tests/Lab Services
Referral Required for Outpatient Diag Procs/Tests/Lab Services
Minimum cost share for diagnostic colonoscopies, maximum cost share for all other services.

Outpatient Diag/Therapeutic Rad Services:
Coinsurance for Medicare-covered Diagnostic Radiological Services 0% to 20%
Coinsurance for Medicare-covered Therapeutic Radiological Services 20%
Copayment for Medicare-covered X-Ray Services $0

Prior Authorization Required for Outpatient Diag/Therapeutic Rad Services

Referral Required for Outpatient Diag/Therapeutic Rad Services

Home Health Services:
Copayment for Medicare-covered Home Health Services $0

Prior Authorization Required for Home Health Services
Referral Required for Home Health Services

Psychiatric Hospital Services:

$1,676 deductible

• $0 copay per day for days 1-60

• $419 copay per day for days 61-90

• $838 copay per day for each lifetime reserve day

These are 2025 cost-sharing amounts and may change for 2026. We will provide updated rates at www.centralhealthplan.com as soon as they are released. 

Prior Authorization Required for Psychiatric Hospital Services
Referral Required for Psychiatric Hospital Services

Outpatient Mental Health Services:

Copayment for Medicare-covered Individual Sessions $0
Copayment for Medicare-covered Group Sessions $0

Prior authorization may be required. 

Referral Required for Outpatient Mental Health Care services.

Outpatient Substance Abuse Services:

Coinsurance for Medicare-covered Individual Sessions 20%
Coinsurance for Medicare-covered Group Sessions 20%

Prior Authorization Required for Outpatient Substance Abuse Services
Referral Required for Outpatient Substance Abuse Services

Over-The-Counter (OTC) Items:

Copayment for Over-The-Counter (OTC) Items $0
OTC benefit include access to herbal products through catalog purchase only.

Combined Group Name: OTC with OTC Hearing Aids

Allowance Amount: $130.00 Every 3 months

Combined Benefit Groups: Over-the-Counter (OTC) Items;OTC Hearing Aids;

Mode of Delivery: Catalogue Purchase, Debit Card;

OTC items may be purchased through debit card or catalogue purchase. OTC hearing aids may be purchased through catalogue purchase. Unused allowance does not carry over to the next quarter.

Podiatry Services:

Copayment for Medicare-Covered Podiatry Services $0
Copayment for Routine Foot Care $0

• Maximum 12 visits every year

Prior Authorization Required for Podiatry Services
Referral Required for Podiatry Services

Skilled Nursing Facility Services:

Copayment for Skilled Nursing Facility Services per Stay $0

Prior Authorization Required for Skilled Nursing Facility Services
Referral Required for Skilled Nursing Facility Services

Medicare Covered Preventive Dental:
Copayment for Office Visit $0

Prior Authorization Required for Medicare Covered Preventive Dental

Non-Medicare Covered Preventive Dental:

Copayment for Non-medicare preventive $0

Maximum plan benefit of $1,600.00 every year for preventive and comprehensive dental services each year

Copayment for Oral exams $0
Copayment for Dental x-rays $0
Copayment for Other diagnostic services $0
Copayment for Prophylaxis $0
Copayment for Fluoride treatment $0
Copayment for Other preventive services $0

Non-Medicare Covered Comprehensive Dental:

Copayment for Non-medicare comprehensive $0
Copayment for Restorative services $0
Copayment for Endodontics $0
Copayment for Periodontics $0
Copayment for Prothodontics, removable $0
Copayment for Maxillofacial prosthetics $0
Copayment for Implant services $0
Copayment for Prothodontics, fixed $0
Copayment for Maxillofacial surgery $0
Copayment for Orthodontics $0
Copayment for Adjunctive general services $0

Eye Exams:
Copayment for Medicare Covered Benefits $0

Copayment for Routine Eye Exams $0

• Maximum 1 Routine Eye Exams every year

Prior Authorization Required for Eye Exams
Referral Required for Eye Exams

Eyewear:

Copayment for Medicare-Covered Benefits $0

Copayment for Contact Lenses $0

Copayment for Eyeglasses (lenses and frames) $0

• Maximum 1 Pair every year

Copayment for Eyeglass Lenses $0

• Maximum 1 Pair every year

Copayment for Eyeglass Frames $0

• Maximum 1 Pair every year

Copayment for Upgrades $0
Maximum Plan Benefit of $300 every year

Prior Authorization Required for Eyewear
Referral Required for Eyewear

Hearing Exams:

Copayment for Medicare Covered Benefits $0

Copayment for Routine Hearing Exams $0

• Maximum 1 visit every year

Copayment for Fitting/Evaluation for Hearing Aid $0

• Maximum 1 visit every year

Hearing Aids:

Copayment for Hearing Aids $49 to $1549

Maximum 2 Hearing Aids every three years

• $49 copay per HA for entry model

• $149 copay per HA for basic model

• $449 copay per HA for prime model

• $849 copay per HA for preferred model

• $1049 copay per HA for advanced model

• $1549 copay per HA for premium model

Prior authorization may be required.

$0.00 copay for Medicare Covered Preventive Services:

Abdominal aortic aneurysm screening
Alcohol misuse screenings & counseling
Bone mass measurements (bone density)
Cardiovascular disease screenings
Cardiovascular disease (behavioral therapy)
Cervical & vaginal cancer screening
Colorectal cancer screenings
Depression screenings
Diabetes screenings
Diabetes self-management training
Glaucoma tests
Hepatitis B (HBV) infection screening
Hepatitis C screening test
HIV screening
Lung cancer screening
Mammograms (screening)
Nutrition therapy services
Obesity screenings & counseling
One-time Welcome to Medicare preventive visit
Prostate cancer screenings(PSA)
Sexually transmitted infections screening & counseling
Shots:

• COVID-19 shots

• Flu shots

• Hepatitis B shots

• Pneumococcal shots

Tobacco use cessation
Yearly "Wellness" visit

• Summary of benefits
• Evidence of coverage
• Star ratings